Attachment 1 - Conflict of Interest.pdf
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- Solicitation number
- 36C24826Q0328
About this file
This is a Sample Conflict of Interest Acknowledgment form from the Veterans Health Administration (VHA) Handbook 1660.03, Appendix A, dated November 4, 2015.
The form is a template to be completed by each Chief of Staff, physician, clinician, researcher, allied health supervisor or manager, and any individual who assumes these duties in the future or any VA employee who participates in Healthcare Contract (HCR) Contracts. The acknowledgment requires signatories to confirm they have received, read, and agree to abide by the guidance contained in VHA Handbook 1660.03 regarding conflicts of interest in contracts or agreements for sharing of HCR. Signatories must also certify that they have completed the appropriate Tier Level Medical Sharing/Affiliate Office Customer training commensurate with their position and understand that the acknowledgment may be placed in their Electronic Official Personnel File with a copy filed in the official procurement file of any HCR Contracts in which they are involved. The form includes signature and date lines for completion.
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